The Devil is in the Details Applying CAUTI and CLABSI Criteria by dffhrtcv3


									  The Devil is in the Details:
 Applying CAUTI and CLABSI
     Criteria Accurately
       Kathy Allen-Bridson RN, BSN, CIC
Business Computer Applications Inc. Contractor to
    Division of Healthcare Quality Promotion
   Centers for Disease Control and Prevention

        Mercer Conference Center
                                             Nov. 2009

1. State the Centers for Disease Control
   and Prevention’s definitions and criteria
   of Catheter-associated Urinary Tract
   Infection (CAUTI) and Central Line-
   associated Bloodstream Infection
2. Correctly identify CAUTI and CLABSI as
   applied to case studies
3. State the correct method to identify
   denominators for CAUTI and CLABSI
   rate calculations.
           NHSN Website
      A Valuable Resource
  NHSN Manual
   – Criteria
   – Key Definitions
   – Tables of Instructions
  Data and Statistics
   – NHSN published reports
   NHSN forms
   Lots more!!!
Horan TC, Andrus ML, Dudeck MA. CDC/NHSN surveillance definition of healthcare-
associated infection and criteria for specific types of infections in the acute care
setting. Am J Infect Control 2008;36:309-32.
Consistency is a Must!
Criteria designed to look at a
population at risk
Identify patients meeting the
Consistently apply the criteria
Ensures the comparability of the
data- protects your facility and
What If My Physician’s
Remind of surveillance vs. clinical
– Diff purposes
– May not be the same
– Comments section useful to note
  important factors
Can submit questions to NHSN
 Healthcare-associated Infection
A localized or systemic condition resulting from an
adverse reaction to the presence of an infectious
agent(s) or its toxin(s) that
 – Occurs in a patient in a healthcare setting and
 – Was not present or incubating at the time of
   admission, unless the infection was related
   to a previous admission
When the setting is a hospital, meets the criteria
for a specific infection (body) site as defined by
When the setting is a hospital, may also be called
a nosocomial infection
Major & Specific
Infection Types
CAUTI and CLABSI Criteria
    and Application
Catheter-associated Urinary Tract
         Infection (CAUTI)
Catheter-associated Urinary
  Tract Infection (CAUTI)
Most common HAI
Rates range between
 – 16.8% in Rehab
 – 3.1% in Med Surg ICU non-major teaching

Renewed interest:
 – Mandatory reporting
 – Denial of CMS reimbursement dollars
    Major & Specific Infection
           Types- UTI
       Major: Urinary Tract Infection
        – Symptomatic UTI (SUTI)
        – Asymptomatic Bacteremic UTI
        – Other UTI (OUTI)

CAUTI= UTI where an indwellling urinary catheter
  was in place in the 48 hours prior to infection
A UTI when an indwellling urinary catheter
 was in place in the 48 hours prior to
 infection onset
*Note: There is no minimum period of time
  that the catheter must be in place I norder
  for the UTI to be considered catheter-
*Note: SUTI 1b and 2b and Other UTI cannot
  be catheter-associated.
  Indwelling Catheter
A drainage tube that is inserted
into the urinary bladder through the
urethra, is left in place, and is
connected to a closed collection
system; also called a Foley
catheter; does not include:
– straight in and out catheters
– Suprapubic catheters
– Nephrostomy tubes
CAUTI Denominator Data

CAUTIs are attributed to patient
# indwelling urinary catheter days/
For urinary catheter device
utilization: # patient days/unit
          48 Hour Rule
If a CAUTI develops within 48
hours of transfer from one inpatient
location to another in the same
facility, the infection is attributed to
the transferring location.

This rule applies to CLABSI surveillance also.
Example of Completed Denominators
   for ICU/Other Locations Form

  10000    Nov       2008   MSICU

   6             6
   8             6
   6             4
   7             7
   6             6
   8             6

   //        //
  151       138
2 Key Questions
Was an indwelling catheter in
place at the time of or within 48
hours prior to the urine specimen
Is the patient 65 years or older?
Symptomatic UTI – 1a & 1b

                       1 a and 1 b
Symptomatic UTI – 2a
Symptomatic UTI – 2b
SUTI for ≤1 year olds –
    Criteria 3 & 4
SUTI 1a & 2a Catheter in
  Place Flow Diagram
Asymptomatic Bacteremic UTI
Determines if
  age is a
  based on
                    Case 1
50 year old patient with end stage pancreatic cancer
with liver & bone mets admitted to hospital with
advance directive for comfort care and antibiotics
only; peripheral IV and nasal cannula inserted
Day 4: patient is febrile and has suprapubic
tenderness; IV ampicillin started after urine obtained
for culture
Day 5: difficulty breathing; CXR=infiltrate L lung
Day 6: urine culture results = 105 CFU/ml E coli
Day 7: WBC/mm3 = 3400; patchy infiltrates in both
lung bases; continued episodes of dyspnea; rales
noted in LLL
Day 11: Patient expired
              Case 1
Does this patient have an HAI?
What type(s)?
SUTI Criteria 1b
–   No catheter last 48 hours
–   Fever in patient < 65 years
–   Urine culture > 10^5 < 2 species
–   (suprapubic tenderness)
Device associated?
    Would you report this HAI?
                    Case 2
POD 3: 66 y.o. patient in the ICU with a Foley
catheter s/p exploratory lap; patient noted to
be febrile (38.9°) and complained of diffuse
abdominal pain
WBC increased to 19,000. He had cloudy,
foul-smelling urine and urinalysis showed 2+
protein, + nitrite, 2+ leukocyte esterase, wbc –
TNTC, and 3+ bacteria. Culture was 10,000
CFU/ml E. coli. The abdominal pain seemed
localized to surgical area
  Is this a UTI?
If so, what type?        Criteria?
                          Case 2
            – Positive urine culture ≥ 103 and
            < 105 with no more than 2 species
            – Pyuria (≥ 10 WBC)
            – Fever (>38°C)
                                                 Yes. Age
            – (+ leukocyte esterase, nitrite)    not factor
                                                 catheter in
What if the patient had been 65 years of
                                                 place at
age? Is it still a SUTI 2a?
                     Case 3
84 year old patient is hospitalized with GI bleed
Day 3: Patient has catheter in place and no signs or
symptoms of infection
Day 9: Patient becomes unresponsive, is intubated and
CBC shows WBC of 15,000. Temp 38.5°C. Patient is
pan-cultured. Blood culture and urine both grow
Streptococcus pyogenes – urine >105 CFU/ml.

Is this a UTI?                 Yes

If so, what type?
                  Case 3
      – No signs or symptoms
      – Positive blood culture with at least
        1 matching uropathogen to the
        urine culture
      – (Fever is not diagnostic for UTI in
        the elderly, therefore fever in this
        age group does not disqualify from
        ABUTI                             No.
What if the organism in both cultures   Micrococcus
had been Micrococcus? Is it still an    not on
ABUTI?                                  uropathogen
                     Case 4
3 week old infant born at 27 weeks gestation.
Umbilical catheter in place. HR 100, RR 32,
and core temperature ranges between 37.8°C
and 36.2°C. Straight cath urine culture yields
>105 CFU/ml Staphylococcus epidermidis.
1 blood culture sent same day, also positive
for S. epi. No susceptibilities provided.

Is this a UTI?            Yes

 If so, what type?
                     Case 4
What if the one blood and urine culture had
been positive for a Micrococcus not

Is this now a UTI?

If so, what type?

For you NHSN it
a BSI?
Laboratory Confirmed Bloodstream
 Central Line-associate Bloodstream
    Infections (CLABSI) Module
  250,000 CLABSIs occur in the
  United States each year1
  Most bloodstream infections are
  associated with the presence of a
  central line or umbilical catheter (in
  neonates) at the time of or before
  the onset of the infection
  Estimated mortality is 12-25% for
  each CLABSI1
Cost to the healthcare system est. $34,000-$56,000/CLABSI
           $296 mil- $2.3 bil.        in US/year2,3,4
            Central Line-associated
             Bloodstream Infection
         CLABSI surveillance utilizes the
         Major Event Type: BSI
         CLABSI= Primary BSI that
         develops in a patient that had a
         central line within the 48 hours
         prior to the infection onset.

NOTE: There is no minimum time period that the central line
must be in place in order for the BSI to be considered central
       48 Hour Rule
CLABSIs are attributed to the
patient location at the onset of the
If the BSI develops in a patient
within 48 hours of discharge from a
location, indicate the discharging
location on the infection report
        Definition: Central Line
A vascular infusion device that terminates at or close
to the heart or in one of the great vessels and is used
for infusion, withdrawal of blood, or hemodynamic
         Definition: Central Line
The following are considered great vessels for the
  purpose of reporting central line infections and
  counting central line days
  Pulmonary artery
  Superior vena cava
  Inferior vena cava
  Barchiocephalic veins
  Internal jugular veins
  Subclavian veins
  External iliac veins
Introduction of a solution through a
blood vessel via a catheter lumen
– Continuous infusions such as
  nutritious fluids or medications, or
– Intermittent infusions such as
  flushes or IV antimicrobial
– Administration of blood or blood
  products in the case of transfusion
  or hemodialysis
Neither the location of the insertion site
nor the type of device may be used to
determine if a line qualifies as a central
Pacemaker wires and other non-lumened
devices inserted into central blood vessels
or the heart are not considered central
lines, because fluids are not infused,
pushed, nor withdrawn through such
Bloodstream Infection
    Definitions :
  Event Type LCBI:
     Criterion 1
LCBI – Criterion 1

      Example: Jon Smith had a PICC line
      inserted on admission (June 1). On
      hospital day 4, he became confused
      and experienced chills. Blood cultures
      were drawn which grew E. faecalis.

      Mr. Smith meets the criteria for LCBI
      Criterion 1.
LCBI Criterion 2
LCBI Criterion 3
Bloodstream Infection: Event
    Type: Clinical Sepsis
One or more blood
 One or more blood
cultures means that at
 cultures means that at
least one bottle from a
 least one bottle from a
blood draw is reported by
 blood draw is reported by
the laboratory as having
 the laboratory as having
grown organisms (i.e., is
 grown organisms (i.e., is
a positive blood culture).
 a positive blood culture).

                              Recognized pathogen does
                               Recognized pathogen does
                              not include organisms
                               not include organisms
                              considered common skin
                               considered common skin
                              contaminants. A few of the
                               contaminants. A few of the
                              recognized pathogens are
                               recognized pathogens are
                              Staph aureus, Enterococcus
                               Staph aureus, Enterococcus
                              spp., E. coli, Pseudomonas
                               spp., E. coli, Pseudomonas
                              spp., Klebsiella spp., Candida
                               spp., Klebsiella spp., Candida
                              spp., etc.
                               spp., etc.
The phrase “two or more blood cultures (BC)
The phrase “two or more blood cultures (BC)
   drawn on separate occasions””means:
    drawn on separate occasions means:
1. That blood from at least two blood draws
1. That blood from at least two blood draws
   were collected within two days of each other,
    were collected within two days of each other,
2. That at least one bottle from each blood draw
2. That at least one bottle from each blood draw
   is reported by the laboratory as having grown
    is reported by the laboratory as having grown
   the same common skin contaminant organism
    the same common skin contaminant organism
   (i.e., is a positive BC)
    (i.e., is a positive BC)
          Determining “sameness”
             of two organisms
If the common skin contaminant from one culture is
identified to both genus and species level (e.g., S.
epidermidis) and the companion culture identifies only the
genus with or without other attributes (in this example,
coagulase-negative staphylococci), then it is assumed that
the organisms are the same.

Report the genus/species to NHSN, i.e., in this example,
report S. epidermidis. See other examples below:
           Determining “sameness”
              of two organisms
If common skin contaminant
organisms are speciated (e.g.,
both are B. cereus), but no
antibiograms are done, or they
are done for only one of the
isolates, it is assumed that the
organisms are the same.
    Determining “sameness” of
      two organisms (cont.)
If the common skin contaminants from the cultures
have antibiograms that are different for two or more
antimicrobial agents, it is assumed that the
organisms are not the same.

             Collecting Blood Culture
Ideally, blood specimens for culture should
be obtained from two to four blood draws
from separate venipuncture sites (e.g., right
and left antecubital veins), not through a
vascular catheter.
These blood draws should be performed simultaneously or
over a short period of time (i.e., within a few hours).

If your facility does not currently obtain specimens using
this technique, you may still report BSIs using the NHSN
criteria, but you should work with appropriate personnel to
facilitate better specimen collection practices for blood
       Case 1
  James is a 28 year old patient with a central
  line who is 3 days post colon surgery on April
  1. He spikes a fever and has blood cultures
  x2 drawn; on April 2, 1 set is negative, 1
  bottle from the second set is positive for
  Bacillus cereus. His doctor orders antibiotics
  and notes “postop sepsis” in the chart.

How should this be reported?
   – Not reported. Does not meet any criteria for
     BSI- common skin contaminant recovered
     from one bottle only
                          Case 1
                                       On April 2nd, another set
                                       of blood cultures are
                                       collected and ½ bottles
                                       grow B. cereus.
                                       Susceptibilities of the 2
                                       organisms are shown:
Organism   Azithromycin   Cetriaxone   Gentamycin   Piperacillin   Vancomycin

   #1           S             R            S             R             S

   #2           S             S            S             R             S
                          Case 1
                                       Is this a BSI?
                                       If yes, what criteria?
                                       If yes, what date of

Organism   Azithromycin   Cetriaxone   Gentamycin   Piperacillin   Vancomycin

   #1           S             R            S             R             S

   #2           S             S            S             R             S
                   Case 1
             Is this a BSI?         Yes
             If yes, what criteria?
             If yes, what date of
                                   April, 1- first date of
LCBI Criterion 2- fever >38°C, not related to
another site, same CSC cultured from ≥ 2
blood cultures drawn on separate occasions.

Antibiograms do not differ for 2 or more
                     Case 1

              What if the patient was 3
              weeks old?

             Still a LCBI. – Criteria 1 and 2
             can be used for patients of any

Is this a CLABSI?

Yes, central line in place or removed within 48
hours prior to event onset.
                             Case 2
A patient with a PICC placed in another facility has
been in our hospital for the past week and now has
a blood culture growing Acinetobacter baumanii.

Is this a BSI? If so, what criteria?
                                           Yes, Criteria 1

Is this a CLABSI?
Yes, central line in place at time of culture

Should it be attributed to our hospital or to the
facility that placed the PICC?
Attributed to our hospital- not present or incubating
at the time of admission- apply the 48 hour rule for
                        Case 2
What if the patient also has an increase in
his sputum, and developed rales, a fever
of 38°C and has two chest xrays with
increased consolidation in his right lower
lobe, in the two days before his blood
Is this a BSI?
Why or why not?
No. Patient now meets criteria of a PNU2:
•Definitive chest xray

• Fever; New rales

•Positive blood culture not related to another source of
infection (blood culture attributed to PNU2)
                    Case 3
An 81 year old patient was in MICU for a week with a
central line in place the entire time. Just prior to
discharge from the MICU to a medical ward, the line was
pulled. Within 36 hours, she became disoriented and
hypotensive. Blood cultures x 2 were drawn and 3 of 4
bottles grew Micrococci and coagulase-negative

Is this a BSI?      Yes- LCBI

Is this a CLABSI?   Yes- Central line in place in 48
                    hours prior to event onset
Criteria?           Crtierion 2- hypotension and
                    CSC from ≥ 2 blood cultures
                     Case 3
Location of attribution?           MICU

Organism(s)?               Micrococcus sp and
                           Coagulase Negative
                          Case 4
  Patient admitted to MICU on 1/21 due to GI bleed
  L subclavian line placed on 1/22
  1/28 patient spikes fever (102.1°F); blood specimen for
  culture drawn through the line x 1; line removed and tip
  sent for culture
  1/3 blood and tip culture positive for coagulase-negative

Is this a CLABSI?
                       No. Catheter tips are not used in
                       NHSN criteria. Therefore only 1
                       blood culture is positive with CSC.
                       No criteria met.
              Case 5

85-year old female admitted from an
extended care facility. Recent onset
confusion and urinary incontinence.
Started on antibiotics.
PMH: Hypertension, recent CVA, Insulin-
dependant diabetic

Day 1: Temp 37.5° C, pan cultured
(blood, urine, sputum). Foley catheter
inserted. Blood sugar 198. PICC line
inserted. Admitted to ICU.
                   Case 5

•   Day 3: All cultures negative, antibiotics
    D/Cd. Blood sugar remains unstable.

•   Day 6: Temp 39.5°. Noted to have
    suprapubic tenderness and shaking
    chills. Pan cultures repeated, antibiotics
    restarted, CXR clear. PICC d/c and tip

•   Day 8: Urine culture ≥105 MRSA. Blood
    culture 2 of 3 and PICC tip positive for
    MRSA. Antibiograms match.
                          Case 5
•   Day 10: Improving urine clear transferred back to
    long-term care on antibiotics.

•   Did this patient have a HAI UTI attributable to your
    facility? If so, what type?
    • Yes, SUTI 1a
        • Fever, (suprapubic tenderness) urine culture ≥ 105
          with no more than 2 species; catheter in place

•   Did the patient have a BSI? If so, is it a CLABSI?
    • BSI: Yes. Positive blood culture.
    • CLABSI :No- Positive blood culture due to other
      recognized cause- urosepsis.
                Case 6
8/14- A 41 year old female presents to the
Emergency Room in diabetic coma and with
anemia. She has a subclavian catheter
inserted in the Emergency Room. The next
day, in the ICU, she has a midline central
catheter inserted for blood transfusions. 8/21-
she develops fever to 39°C, and shaking chills.
2 sets of blood cultures sent.
8/15- blood cultures positive for Pseudomonas
aerginosa. Neither insertion site shows
inflammation and there is no other
documented infection
         Is there a BSI? If so, what type?
           – Yes. LCBI
           – Criterion 1
                • Pathogen cultured from 1 or more blood
Case 6            cultures
         If so, which line should the BSI be attributed to?
           – If the tip of the midline catheter does not end in
             one of the great vessels or at or in the heart, then
             it is not considered a central line. Therefore the
             CLABSI would be attributed to the subclavian line.
             If two central lines are in place, and If unable to
             identify one line as source, attribute to the oldest
             line. If both central lines were inserted at the
             same time, attribute to the one with the highest
             risk i.e. temporary vs. tunneled, femoral vs
             subclavian, etc.
           Case 6
What unit should be indicated for
the Location of Device Insertion
– The Emergency Department.
  However, this field is optional.
  CLABSI will be attributed to the
  ICU since ED is not an inpatient
  location and no denominator data
  are collected there.
                Case 7
Day 1: One-day-old twin male infant admitted
and emergently transferred to Neonatal
Intensive Care Unit. Vented in isolette during
transport. Peripheral IV in scalp, IV fluid at
1cc/hr with Prostin (0.05mcg/kg/min) started
prior to transport, and umbilical catheter
inserted upon admission to NICU.
Neonatal History: Gestational age-term
infant, birth wt. 1810 grams, Apgars 8 & 9.
A cardiac echocardiogram showed
transposition of the great vessels of the
                    Case 7
Day 3: Repair of Patent Ductus Arteriosus and Atrial
Septal Defect performed; later that day the umbilical
catheter site was noted to be slightly red.
Day 4: umbilical catheter site remained slightly red
and a low grade temperature developed.
Day 5: the umbilical line was pulled, 1 blood culture
was drawn and the umbilical catheter tip was sent for
Day 6: continued elevated temp of 38.1° and
antibiotics were started.
Day 7: the culture and umbilical catheter tip were
both positive for Aerococcus sp. Antibiotics adjusted
as needed for coverage. Patient clinically improving.
                 Case 7

• Does this patient have an HAI?
• If so, what type? Criteria?
    • No. Because the catheter tip is not used
      for meeting NHSN criteria, there is only one
      positive blood culture for Aerococcus , a
      CSC. Therefore patient does not meet
•   Does the baby meet criteria for CSEP?
    • No. A positive blood culture is not
      included in the CSEP criteria (blood culture
      not done, or no growth).
                Case 7

• What if both cultures were positive for
  Staphylococcus aureus?
  • LCBI-Criteria 1- 1 blood culture positive for
    pathogen (catheter tip still not used)
             Case 8
Baby girl Jones is born at 35
weeks and weighs 1200 grams at
birth. An infusion line is placed
into her umbilical vein after
admission to the NICU. 2 days
after birth, her core temperature
drops to 35° C, she is diagnosed
with sepsis and started on
antibiotics. A single blood culture
is drawn and returns positive for
Candida albicans 2 days later.
            Case 8
Is the criteria for a lab confirmed
bloodstream infection met?
–   Yes. LCBI Criterion 1- Pathogen
    recovered from blood.
If her blood culture had been
negative, would the criteria for
clinical sepsis be met?
–   Yes
What would be assigned as a
–   CSEP has no identified pathogen
                    Case 8
What criteria would be met if blood
cultures had been drawn on Day 2
and Day 3 and both were positive
for S. epidermidis with the same
–       LCBI Criterion 3:
    •     Patient 1 year or younger,
    •     Hypothermia
    •     CSC from 2 or more matching blood
          cultures on separate occasions
                  Case 9
6/4-49 year old diabetic patient admitted in
diabetic coma. Patient with left foot with painful
swollen, red and warm to touch, but without
drainage. Subclavian line inserted in E.R. Patient
admitted to MICU. Temp 37.8°C. Antibiotics
begun for “cellulitis”
6/6 Temp 38.2°C. Hypotension. Blood cultures x 2
sets collected.
6/7 Staph aureus cultured from blood x2.
                       Case 9

Does this patient have an BSI?

Yes- pathogen recovered from blood culture.

Primary or secondary?


   What is the                    SKIN- Criteria 2
primary infection?
Case 9
Collecting Summary Data
NHSN Protocol for the collection of
device-associated infection
 – Patient Days: at the same time
   every day count the number of
   patients on the unit
 – Device Days: at the same time
   every day, count the number of
   patients with one or more devices
   (pt with >2 gets counted as 1)
Collecting Summary Data
Data collected differs according to
 – SCAs:
    • # pts.with permanent central lines
    • # pts with temp central lines
    • Pts with both count only temp line
 – NICUs: stratified by birthweight
    • # pts with central line
    • # pts with umbilical line
    • Pts with both count only umbilical line
Collecting ICU/Other
  Summary Data
Collecting SCA Summary
Collecting NICU Summary
               Collecting Summary Data
               MICU – collecting patient days and
               device days on June 8 at noon
Patient          ADT              Vascular          Urinary            Respiratory
101 Smith        Home @ 9 am      PICC home w/      Indwelling foley   O2 @2L/min
                                  pt                to DD              cont
102 Washington   Day 3            Peripheral IV     Bedpan – cath      IPPB q 6 hours
                                                    spec to lab
103 Doe          Adm 10 am        IJ CL inserted    Voiding            O2 @ 2L/min
                                  at 2 pm                              prn
104 -----
105 Chen         Day 2            Swan Ganz         Suprapubic to      Intubated/vent
                                  and               direct drainage
106 Jones        Day 8            Subclavian CL     Indwelling foley   Trach / vent
                                  cont              to DD
107 Gonzales     D/C to nursing   Peripheral line   Incontinent        Suctioned prn
                 home @ 4 pm      d/c at 1 pm
          Collecting Summary Data
                        Patient        ADT
How many patient days
                        101 Smith      Home @ 9 am
are counted for this
MICU on June 8?         102 Washington Day 3

A. 7                    103 Doe        Adm 10 am
B. 6
                        104 -----
C. 5                    105 Chen       Day 2
D. 4
                        106 Jones      Day 8
E. 3
                        107 Gonzales   D/C to nursing
                                       home @ 4 pm
           Collecting Summary Data
How many central line   Patient          ADT              Vascular
                        101 Smith        Home @ 9 am      PICC home w/
days?                                                     pt
A. 6                    102 Washington   Day 3            Peripheral IV
B. 5
                        103 Doe          Adm 10 am        IJ CL inserted at
C. 3                                                      2 pm
D. 2                    104 -----
                        105 Chen         Day 2            Swan Ganz and
E. 0
                        106 Jones        Day 8            Subclavian CL
                        107 Gonzales     D/C to nursing   Peripheral line
                                         home @ 4 pm      d/c at 1 pm
          Collecting Summary Data
How many indwelling   Patient          ADT              Urinary
                      101 Smith        Home @ 9 am      Indwelling foley
catheter days?                                          to DD
A. 6                  102 Washington   Day 3            Bedpan – cath
B. 5                                                    spec to lab
                      103 Doe          Adm 10 am        Voiding
C. 4
D. 3                  104 -----
                      105 Chen         Day 2            Suprapubic to
E. 2
                                                        direct drainage
F. 1                  106 Jones        Day 8            Indwelling foley
                                                        to DD
                      107 Gonzales     D/C to nursing   Incontinent
                                       home @ 4 pm
AJIC: American Journal of
Infection Control, Volume 36, Issue
5, Pages 309-332, June 2008,
Authors:Teresa C. Horan; Mary
Andrus; Margaret A. Dudeck.
                   Save the Date
                 Fifth Decennial
           International Conference on
               March 18-22, 2010
                     Hyatt Regency Atlanta
                       Atlanta, Georgia

Co-organized by:

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